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Bad Medicine, Part 3: Death by Diagnosis (Ep. 270)

How can it be that medical error is the third-leading cause of death in the U.S.? And what’s to be done? (Photo: jasleen_kaur/flickr)

Our latest Freakonomics Radio episode is called “Bad Medicine, Part 3: Death by Diagnosis” (You can subscribe to the podcast at iTunes or elsewhere, get the RSS feed, or listen via the media player above.)

By some estimates, medical error is the third-leading cause of death in the U.S. How can that be? And what’s to be done? Our third and final episode in this series offers some encouraging answers.

Below is a transcript of the episode, modified for your reading pleasure. For more information on the people and ideas in the episode, see the links at the bottom of this post. And you’ll find credits for the music in the episode noted within the transcript.

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David KESSLER: “This is an American condition. This is an American disease. This has been one of the great mistakes of modern medicine.”

That’s David Kessler, who ran the Food and Drug Administration during the 1990s. Surely you know the condition, the disease, he’s talking about. President Obama has been talking about it …

President Barack OBAMA: This crisis is taking lives. It’s destroying families. It’s shattering communities all across the country.

But what does Kessler mean when he says “this has been one of the great mistakes of modern medicine”?

OBAMA: Drug overdoses now take more lives every year than traffic accidents. A lot of time, they’re from legal drugs prescribed by a doctor.

What Kessler is talking about is a combination of good intentions, greed, and a complicated, changing relationship between doctors and their patients. The result: people dying every year from prescription drugs that are supposed to heal us, not kill us. That’s a sick twist, isn’t it? So how’d this happen?

KEITH WAILOO: It’s part of the recurring sense of hope and despair associated with these drugs that are supposed to solve problems, but they end up being problems in themselves.

The numbers are remarkable.

ANUPAM JENA: Prescription opioid use has gone up about 300-400 percent since the year 2000.

America is a world leader in the consumption of painkillers. Here’s what a 2007 report found:

WAILOO: We were consuming about 83 percent of the world’s oxycodone in the United States. And it is not because we had 83 percent of the world’s pain. It’s because we are a consumer society that believes in the power of the magic pill.

How did medicine get taken over by consumerism?

MARTIN MAKARY: Doctors used to practice medicine on sick and injured patients, and it was those two players in the health care system. And now the same two people in the room, the doctor and the patient — behind the room is a gigantic industry of people buying, selling, trading, bartering, discounting, marking up all of our services.

Today on Freakonomics Radio: the third and final part of our “Bad Medicine” series. This time, we look at the doctor-patient relationship. Who’s got the real leverage in that relationship?

MAKARY: They cope with their job by giving an angry patient what they want, not what they need.

What’s the number-one problem in health care?

MAKARY: I think the number-one problem is we don’t measure performance. We don’t measure the outcomes of patients in health care for 99 percent of the health care that’s delivered.

And … is it a better idea to just stay away from the doctor?

DUBNER: So I would think that you are a downright danger to your patients. How is it that you’re not?

JENA: Haha! No comment.

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In the first two episodes of our “Bad Medicine” series, we looked at some of medicine’s biggest mistakes:

TERESA WOODRUFF: It would cause a whole series of malformations and probably a lot of fetal death.

VINAY PRASAD: It was literally taking someone to hell and back.

And we looked at how better science is pushing medicine not always forward, but often backwards.

JENA: It is quite common to see practices that end up getting reversed. And the best estimates are that happens about 15 percent of the time.

We talked about who has been excluded from a lot of clinical trials.

TERESA WOODRUFF: The study of women in general became part of the collateral damage.

And, these days, who gets included:

BEN GOLDACRE: When you look at the evidence, what you often find is that trials are often conducted in absolutely perfect dream patients. People who are, by definition, much more likely to get better quickly.Now that’s very useful for a company that are trying to make their treatment look like it’s effective. But actually, for my real-world treatment decisions, that kind of evidence can be really very uninformative.

Today, in our final episode of “Bad Medicine,” we focus on those real-world treatment decisions. We focus on where health care really happens — when a patient gets together with a doctor, or another health care professional. And what’s one of the main reasons any of us might go to a doctor? That’s easy: because we’re in pain.

WAILOO: Pain illuminates what is, I would argue, a general problem in medicine.

WAILOO: That is to say, who’s to say what degree of pain a person is in and what constitutes truly effective relief, other than the patient themselves? And two different people might require different doses of medication to alleviate the pain.

In the late 1980s and early 90s, there was a push to mandate the recognition and treatment of pain. This culminated in the promotion of pain as the fifth vital sign, along with temperature, blood pressure, pulse, and respiratory rate. Which made pain the only vital sign that is determined not by objective measurement, but by the patient’s own assessment.

So doctors were put in the position of having to determine whose pain was worthy of a prescription pain-killer and whose wasn’t. Very often, doctors have decided “yes.” In 2015, more than 650,000 opioid prescriptions were dispensed per day in the U.S.

One result of this prescription onslaught? It is believed to have contributed to a recent uptick in mortality rates. Anupam Jena is a physician and a health care economist at Harvard.

JENA: Mortality rates in the U.S. have risen for the first time in 10 years.

Which is striking, considering that mortality rates have been falling for at least 100 years. The U.S. rise has been concentrated among a few groups — particularly white, middle-aged men and women. Among white men with a high-school education or less, the death rate has risen an astonishing 22 percent.

JENA: And the attribution of these issues is, in part, due to opioids. And this is a problem that was created by medicine.

DUBNER: And yet you certainly can’t blame your profession for that because it’s an effective drug when used well, correct?

JENA: Correct, yeah. You know like many drugs in medicine, they’re effective in certain situations. So for patients who fall at home and break their hip and have a hip fracture — opioids for situations like that are known to be effective pain relievers. Or in patients with cancer, particularly in cancer with bone pain, because of disease that has metastasized to the bone. Opioids in that situation have been shown to be highly effective in terms of reducing pain. But opioids for low back pain, or headaches, or knee pain, or hip pain or just chronic pain in general, opioids are not thought to be an effective strategy and yet we’ve seen the proliferation of their use in the last decade.

So how do you maximize the use of opioids when appropriate and minimize their overuse? That’s not easy; there are a lot of confounding factors. But it’s hard to come up with good prescribing protocols for pain relievers when you don’t even have good measurement for pain.

WAILOO: Because we don’t have any objective measures for actually figuring out what works, we are necessarily in a realm where not subjective assessment,but also trial and error medicine is necessary to figure out what works.

And to that end, Wailoo says …

WAILOO: We need to think about over-medication and under-medication as not two poles of the use of pain medicine, because then what we do is that we kind of just whiplash, like a pendulum. We go from believing that under-medication is a problem to believing that over-medication is a problem. What we need to do is to understand that both of these things can be a problem at the same time.

The American Medical Association, hoping to address this problem, recently turned back the clock; it recommended that pain be removed as a fifth vital sign. But how much will that help? Anupam Jena again:

JENA: As an economist, I think about supply and demand. So there’s the demand of patients, increasing demand by patients for opioids.

Once you’ve put the power in the hands of the patient — or, just to call it what it is, in the hands of the consumer — it can be hard to reclaim it. So how did we get here?

WAILOO: Yeah, sopain management was really emerging as a recognizable and legitimate area of medical practice and care in the 1960s, early 1970s, with the development of multidisciplinary pain centers.

Keith Wailoo again.

WAILOO: There was a general recognition that you needed more than just drugs to deal with people in chronic pain. You needed social workers, you needed surgeons, you needed psychologists, you needed a wide range of others as well as people with pharmacological expertise.

But those multidisciplinary pain centers were really expensive.

WAILOO: And so, you know one of the economic trends, since the 1980s, with the rise of cost containment, is to sort of see drugs as the cheapest and the fastest solution to our problem.

This coincided with a big shift in how drugs are marketed to the public.

WAILOO: Before the 1980s, the idea that you would see prescription drugs being advertised on television was laughable. It emerges in the mid-1980s that, you know, we’re sort of seeing government regulation as the problem and the market as the solution to our problems. And out of this era emerges this idea that people have the right to have the information at their disposal, about prescription drugs, and to bring that knowledge into the physician’s office in order to — not so much demand — but to shape clinical decision-making.

In fact, the aggressive marketing of Oxycontin as a safe pain medication led to criminal convictions for top executives at its manufacturer, Purdue Pharma, for misleading the FDA, clinicians, and patients about its risks. But just because one painkiller is declared risky doesn’t mean that consumers wouldn’t demand others pain-killers. Because, as Keith Wailoo told us earlier …

WAILOO: We are a consumer society that believes in the power of the magic pill.

And once consumers gained more leverage in the medical realm, guess whose opinions began to matter a lot more? Yep, the consumers’. In the form of those patient-satisfaction surveys you fill out after a doctor’s visit.

MAKARY: Yeah. It is a problem. That’s the problem, when we just measure things that are easy to measure.

MAKARY: By putting all this attention on customer satisfaction or consumer satisfaction or patient satisfaction, we’re creating a consumerist culture in health care. People come in, they want an antibiotic for their kid, and they don’t care what your diagnosis or explanation is, they want to walk out with that antibiotic prescription. Or you’re in pain and you want that pain script. If the doctor is under the microscope for their patient-satisfaction scores, you can imagine the perverse incentive here.

Indeed. A 2012 paper in the Journal of the American Medical Association pointed to an unintended consequence of this perverse incentive. “Physicians who do not comply with patient requests,” the authors wrote, “may be the recipients of poor ratings on patient satisfaction scores, possibly resulting in emotional, financial, and professional penalties.”

So imagine this. You are a doctor and your patient asks, maybe by name, for a prescription pain-killer. You may think the patient doesn’t really need it; you may, in fact, be worried they’ll abuse it, maybe even sell it. But if that consumer has the ability to punish you professionally … well, you might just write the scrip.

MAKARY: They respond to demands. They cope with their job by giving an angry patient what they want, not what they need, because they have to see five patients in an hour. I can tell you, emphatically, doctors are getting crushed out there. They’re getting crushed with record rates of burnout due to increasing overhead, higher malpractice premiums, declining pay, lowering Medicare reimbursement, being forced to see more patients in a single hour, corporate medicine.

On top of all that, Makary says, there’s a brutal paradox. Patient satisfaction is not a helpful metric when it comes to measuring health outcomes. Well, at least not helpful in the direction you might think it would be. A 2012 study found that the most satisfied patients had higher rates of hospitalization and higher mortality rates. Why? The authors suggest that more “satisfied” patients may request more discretionary treatments, which may increase the likelihood of adverse effects.

MAKARY: So, it’s a big problem. What’s important to a patient when they come to a doctor? The doctor’s patient satisfaction score? Well, that’s a piece of the doctor’s quality. But really what you’re interested in is the doctor’s judgment, and the doctor’s skill, and the doctor’s ability to empathize.

Those are the sort of metrics, Marty Makary argues, that will help doctors treat patients better. So, coming up on Freakonomics Radio: now all you have to do is collect all the data on doctors’ judgment, skill, and empathy, right? But, again, not so easy — in part because of the sheer volume of that data …

MAKARY: We are doing more than we’ve ever done before. We are doing more procedures, giving more medications, hospitalizing more patients, diagnosing more things than we ever have in the history of medicine.

Also, why feedback for doctors is so important — especially for doctors who’ve been practicing a while.

JENA: What we find is that if you happen to be treated by a doctor who is 10 years or 15 years out of residency, your mortality within thirty days of being hospitalized is higher.

Marty Makary, the surgeon and health-policy scholar we’ve been speaking with, is a big advocate for medical reform. First step: improving the feedback loop. That is, what we know and, way too often, what we don’t know, about what actually works.

MAKARY: I think the number-one problem is we don’t measure performance. We don’t measure the outcomes of patients in health care for 99 percent of the health care that’s delivered.

Makary might be exaggerating a bit but still — how can this be? When you go in for medical treatment, don’t the health professionals who treat you find out if their intervention actually worked? The short answer is, often, no. But the longer answer is much worse.

The longer answer is that not only do medical interventions often not work; medical interventions will sometimes kill you. Marty Makary and a co-author, Michael Daniel, recently published a study arguing that the third-leading cause of death in the U.S., after heart disease and cancer, was … medical error. I’m going to say that again: the third-leading cause of death in the U.S., accounting for 10 percent of deaths annually, is medical error.

How can this be? Are doctors and nurses showing up for work stoned out of their skulls? Are they sneaking into hospital rooms at night and smothering their most annoying patients? Are they surreptitiously removing healthy organs to sell them on the black market? If only! That would make the problem so much easier to solve. Why are so many deaths the result of medical error?

MAKARY: Well, I think anybody that practices medicine knows that medical errors are a function of the amount of things we do in health care.

“The amount of things,” meaning what?

MAKARY: We are doing more than we’ve ever done before. We are doing more procedures, giving more medications, hospitalizing more patients, diagnosing more things than we ever have in the history of medicine. Right here, today, in the United States. We have the most medicalized, the most diagnosed population in the history of the world.

In economic terms, you could say there’s both an oversupply and an over-demand of health care, since the supply and demand are both fueled by the setup of our health care insurance system. Patients who buy expensive insurance want to get their money’s worth, and may over-consume, just as you might overconsume at an all-you-can-eat restaurant. And doctors who make money primarily when they do stuff may tend to do more stuff.

MAKARY: When we’re doing all of this stuff, it makes you wonder, does that mean we’re also making mistakes proportional to the amount of stuff we do?

Well, that sounds scary.

MAKARY: So first of all, I don’t want to scare people out there. Most doctors are doing the right thing and always will.

Alright, but how can it be that the people we entrust to heal us, the people who’ve worked their entire adult lives to learn how to heal us, may sometimes be killing us? To get to the answer, you first have to understand that for decades, we’ve been making a sort of clerical error.

MAKARY: Our research found the methodological flaw in our country’s national health statistics. We use a billing code system to tally causes of death from death certificates. And people don’t just die from billing codes. They die from medical mistakes, communication breakdowns, overdoses, fragmented care, closed insurance networks, preventable complications, unnecessary treatments, and if you look collectively at this group of problems, let me call it “medical care gone wrong,” it’s got a significant burden in society.

But those complications and oversights and errors, Makary says, seldom wind up on the death certificate.

MAKARY: When you fill out the death certificate, you have to list the reason the patient died. Both the direct reason and the underlying reason a patient died. Well, we all knew what the real reason was, but you can’t put that on someone’s death certificate.

Why not?

MAKARY: When somebody experiences a fatal mistake — their heart stops and then you do CPR, then you pronounce them dead. What do you put on the death certificate when it says, “What was the cause of the patient’s immediate death?” That’s what really got us thinking and that’s what led to this study. Because you end up putting “cardiovascular arrest” and then it turns out what we put on the death certificates populates our country’s national health statistics. So when the government puts out every year, “these are the most common causes of death in the United States,” and by the way, that list is a big deal. That list informs all of our research funding, it informs all of our public health campaigns in America, that list is a big deal. You realize we’re misclassifying medical mistakes as other causes, and that medical mistakes don’t even show up on the list.

So Makary and his colleagues got hold of a mountain of data and started digging.

MAKARY: Well, we basically looked at the best available research on the topic from the New England Journal of Medicine and Health Affairs, and a big Medicare analysis, and something called the OIG report, it was a government report that was independent.

And what they’d find? Before I tell you that, let me tell you this. There’s a famous report, put out by the Institute of Medicine, in 1999, that set a benchmark for death by medical error. That report estimated there were between 44,000 and 98,000 deaths annually in the U.S. due to medical error.

Those are obviously large, and frightening, numbers — so large and frightening that I’ve heard many, many medical professionals insist those numbers had to be way too high. So … what number did Makary come up with? At least 250,000 deaths every year in the U.S. due to medical error. A quarter of a million people!

Before we get into the errors themselves, let’s think for just a minute about how the story of those deaths was hidden in the data. As we’ve noted throughout these three episodes on “Bad Medicine,” a lot of what we take as factual and empirical within medicine often isn’t very empirical at all. That includes how data from clinical trials are manipulated or misinterpreted. And, as Marty Makary argues, it includes how the cause of death is categorized.

That’s why he’s pushing for a fundamental reform: to require that doctors, when they fill out a death certificate, specifically indicate if a medical error was involved. Because how do you solve a problem if you don’t even acknowledge the problem? And with medical errors, the problem is both deep and broad.

JENA: Medical errors have a complex taxonomy.

That, again, is the Harvard doctor and economist Anupam Jena.

JENA: But for someone like me, I would just break them into two categories. There are errors of diagnosis and then there’s errors of commission, when a patient has surgery on the wrong leg or when a patient is given an antibiotic despite it being well-documented in the medical record that he or she has an allergy to that medication. Or when a patient receives a dose of insulin that is five times as much what it should have been because someone couldn’t read a doctor’s handwriting in the chart. There are errors that occur in the hospital because of poor hygiene and infectious-disease management where people get hospital acquired infections.

DUBNER: I’ve got to think that those errors of commission are extraordinarily rare though, yes?

JENA: Well, you would hope so but it turns out that they’re not. The Johns Hopkins study was actually more about those second set of errors.

DUBNER: So when I hear that, I as a potential patient, I say to myself, “Self, unless you are bleeding heavily or unconscious, just stay away from every doctor and certainly every hospital.”

JENA: Well hopefully if you’re unconscious you won’t be making that decision. Well, you know I think you also have to take a step further and say okay, when a diagnostic error occurs, what is the implication of that? Does it mean that the diagnosis is ultimately made later in a safe and effective way? Well, that’s much less alarming than if an incorrect diagnosis by a doctor leads to, let’s say, a biopsy that then causes longer-term problems.The only thing I would mention is that this is not just an issue of decisions that are made by individuals. In fact, most of the thinking on this issue points to system-level problems that lead to diagnostic errors.

MAKARY: I think the number-one problem is we don’t measure performance.

In other words: the medical system often fails to collect useful feedback.

MAKARY: Simple data, simple transparency.

Makary himself is a surgeon.

MAKARY: Ninety-nine percent of people that have surgery in the United States go home and no one documents or keeps track at a systematic level — that is, national or regional, or hospital — how the patient does. At six months, are you glad that you had your knee surgery done? At six months after hip surgery, are you walking again? Or a year after weight-loss surgery, what is your weight today? We don’t keep track of those things in health care for most of the procedures or treatments that we do. The problem is that how can you really come up with a quality metric if nobody’s tracking it?

This doesn’t mean doctors never check in with their patients. But the system simply isn’t designed to capture robust follow-up data.

MAKARY: Well, there’s a follow-up visit. You know, we’ll scribble some note. “Patient is doing well. Incision has healed nicely.” Who’s actually measuring the real patient-centered outcomes six months later? Or a year later? That is a giant opportunity in health care to fix the system by creating a marketplace centered around value, not just around quantity.

That, of course, would require incentives for doctors that reward preventive care and maintenance rather than just interventions. Makary points to a few areas of medical care where patient outcomes are well tracked.

MAKARY: But it’s only for a small sliver of medical care. It’s like heart surgery and cystic fibrosis outcomes.

In those cases, he says, money plays a big role.

MAKARY: It’s almost this hodgepodge of conditions where there’s been leaders and good funding or foundation support.

But absent good follow-up data, and absent good feedback in general, it’s hard to tell what works and what doesn’t. Of course this is true for anything, not just medicine. But with medicine, the stakes are high — and, if you’re the patient, the stakes are practically infinite. You are putting your life in someone’s care, and you only have one life (as far as we know).

Other choices might seem hard — which house to buy or how to invest your money, how to pick a career, or a college major. But if you’ve got a serious health concern, your choice of treatment, and doctor, is an existential choice. So, given a choice between two doctors, let’s say — one fresh out of medical school and the other with fifteen years’ experience, which one do you go for?

JENA: I think one question that any patient would have when they see a doctor is how much experience does my doctor have?

That’s Anupam Jena again. Most patients, he says, like the idea of a gray-haired physician.

JENA: Because the gray-haired physician has more experience; he’s seen more patients like me and he’s just going to take a better care of me.

That makes sense, doesn’t it?

JENA: But the challenge is that there has not been a lot of actual high-quality evidence to assess that issue.

So Jena and some colleagues set out to gather some evidence. But it wasn’t so simple as comparing patient outcomes for experienced doctors and newer doctors.

JENA: One problem that you’re going to run into is the notion that more experienced physicians will take care of sicker patients. So how do you get around that issue? The way that we’ve tried to get around it is to focus on a very specific group of doctors that are called hospitalists. Hospitalists are internal medicine doctors who focus on hospital-based care.

Jena is himself a hospitalist. Because of his research and teaching, he only sees patients for a month or two of each year; but he’s familiar with the hospitalist setup.

JENA: And the unique thing about these types of doctors is that they tend to work either shifts or scheduled work. For example I might work for two weeks and then my colleague is on for two weeks and then her colleague is on for two weeks.DUBNER: Which is nice because we can isolate the effect of you, correct?

JENA: Exactly. So patients more or less end up getting quasi-randomized to physicians with different characteristics. So for example if you happen to get hospitalized in the first week of May, you may be treated by a group of doctors who on average have five years’ less experience than if you happen to get hospitalized in the second week of May. And we can basically see what happens if a patient happens to be treated by a doctor who is 20 years out of residency versus 5 years out of residency. And what we find is that if you happen to be treated by a doctor who is 10 years or 15 years out of residency, your mortality within thirty days of being hospitalized is higher.

Just to be clear, if you happen to draw a more-experienced doctor, you are more likely to die.

JENA: And so it does suggest that more experience actually could have a negative effect on outcome.DUBNER: And what’s your best explanation for why that’s the case?

JENA: So I think the most likely explanation is two things. One is that the field of medicine is constantly evolving and there is always new knowledge, new evidence emerging both in terms of how to make better diagnoses and what are the right treatments for a particular patient. As you get further and further away from residency, I think what happens is that the knowledge that you had as a resident, which time that you spent 80 to 100 hours per week in a hospital, that knowledge gets somewhat ingrained in you. New knowledge isn’t picked up as rapidly. So I think what happens is older physicians are just less-up-to date, if you will. I’ll give you one caveat. We don’t see this effect among high-volume doctors — doctors who are seeing a lot of patients. So what that suggests that if you are an older doctor who is seeing a lot of patients, you are protected from this adverse effect. Which makes sense.

MAKARY: Unfortunately, some people come out of medical school or training thinking, “All right, I’ve mastered this body of knowledge or this skillset, and I’m good to go for the next 50 years of practice.”

Marty Makary again.

MAKARY: And the reality is, even as a tenured faculty at Johns Hopkins doing complex surgery in a group that does — you know, the four of us do the most pancreatic surgery of any group in the country — I’m still learning every day. And my senior, senior partner, who’s about to retire, he’s still learning the year before he stops operating every day. So, medicine is a career of learning. And I think the more feedback we can get, at any level.

That said, Anupam Jena’s research shows that surgeons are among the subset of physicians who do seem to improve with experience.

JENA: There’s a thought that muscle-scale experience in the surgical field over time improves outcomes, and we find that as well. But outside of surgery, when you’re thinking about the care of patients that requires a lot of cognitive skill and being up to date on current medications and diagnoses, we actually find that over time, older doctors do worse.

DUBNER: So someone like you — so, I don’t mean to turn this into an attack on you, but someone like you who a) medical school is getting further in the rear-view mirror as it is for every doctor, but additionally you’re only practicing for a couple of months out of the year, not full-time. So I would think that you are a downright danger to your patients. How is it that you’re not?

JENA: Haha! No comment. Well you know so usually when I work on service I am paired with someone who is a full-time clinician educator and there is a huge difference in the amount of knowledge. And it’s very humbling to see that.

[MUSIC: Pat Andrews, “Difference in Me”]

Jena’s research looks specifically at physician experience as it relates to patient outcomes, but there’s another angle to consider when we talk about experience in the medical realm. Especially if you’re interested in reform. We have supposedly entered the era of evidence-based medicine. This is still relatively new ground.

PRASAD: The reality was that what we were practicing was something called eminence-based medicine.

PRASAD: It was where the preponderance of medical practice was driven by really charismatic and thoughtful, probably, to some degree, leaders in medicine. And you know, medical practice was based on bits and scraps of evidence, anecdotes, bias, preconceived notions, and probably a lot of psychological traps.

As outdated as that sounds now, keep in mind that a lot of our institutions — including medical institutions — are still “eminence-based.” Which is to say, in many institutions, many big decisions were made by the highest-ranking people, who tend to have the most experience — and people with a lot of experience tend to have fixed views on things. They’re attracted to the status quo, or some minor variation of it. Because that’s what they know; it’s what they trust and believe in.

Also, if you wanted to a bit uncharitable for a moment, we might argue the status quo is additionally appealing to senior people because — well, because they’ve got theirs already. Their job, their status, their salary. And all that disruption that reformers like to talk about — well, it’s messy. It’s time-consuming. It’s a pain in the neck. Like I said, that isn’t a charitable view, but I’m afraid it’s not wrong either. Change can be hard; uncertainty can be scary; true improvement can be elusive.

But one thing that’s so inspiring about all the people we’ve been speaking with for this series is how they embrace the notion that it’s okay to challenge the very institution that you’ve devoted your career to. In fact, with medicine, it’s a requirement.

I think back to something we heard from Philip Mackowiak, the doctor who unraveled the true story of 98.6:

PHILIP MACKOWIAK: As a medical historian, it is patently obvious to me that future generations will look at what we’re doing today and ask themselves “What was Grandpa thinking of when he did that and believed that? Look at us now how good we are. Why weren’t they that good?” And they’ll have to learn all over again that science is imperfect and to maintain a healthy skepticism about everything we believe and do in life in general, but in the medical profession in particular.

So what happens now? There’s a long list, and reasons to be excited. Marty Makary is particularly enthusiastic about new ideas for collecting better patient feedback.

MAKARY: Well, Washington state has a really neat program in select hospitals. After you have a certain operation, you get a text question. It says, “How functional are you after your surgery?” Here’s a scale from 1 to 5. “Are you glad that you had the procedure done? Do you feel that the alternatives were adequately explained to you before the procedure?” And those few questions populate a quality database and they keep track of outcomes. But that’s a rare thing in health care. We need to be doing that for every procedure in the United States. Everyone in the United States that has robotic surgery or a tonsillectomy or gallbladder removal or heart surgery or colon or whatever it is, should have some data that follows up and allows us to make conclusions about where we can do better, what’s working and what’s not working. You know, we just discovered — or rediscovered, if you will — that we don’t really need to treat appendicitis with surgery. You can come in with early appendicitis and we can give you antibiotics and it works more than 60 percent of the time. That’s cool, and we probably could have learned that if we had the right databases to look at those conclusions to say, “Hey, of those patients that refused surgery and we just gave them antibiotics for the last half century, how did they do?”

Makary says a lot of this change is being driven by players outside the medical establishment.

MAKARY: It’s happening, really, led by startup companies. The startup community in America is doing great things in health care and they’re starting to say, “Hey, can we track how well someone does after surgery? How was your experience? How was your outcome? How was the care you received after whatever procedure you had done?” With enough time and with enough patients, they’re going to actually be able to make conclusions about quality using firsthand patient data.

But given the complexities of medicine, Makary warns, we shouldn’t expect quick fixes.

MAKARY: First of all, it’s different in every area of medicine. If you’re a cardiologist or an OB or a psychiatrist, you can’t simply implement strategies to improve quality and standardize care in the same way. In my own field of surgery, we believe there’s something that can be done that’s called benchmarking. That is, we can see how we stand as a surgical group, as individual surgeons, relative to other surgeons in our region and nationally that take on similarly complex cases. That’s why we’ve proposed — and we have a grant to do this nationally — we want the doctors’ associations to come up with a metric of performance. We want to apply it to all the doctors in that specialty. And then we want to share the data with the doctors individually in a confidential, peer-to-peer, civil fashion. This is where you stand. This is where the rest of the country stands. We’re not making a judgment. We just want to share with you your data.

The point, Makary says, is improvement, not punishment.

MAKARY: As a matter of fact, firing people for making mistakes in hospitals is the absolute wrong approach. We need to learn from our mistakes, not send a message that if you have a concern or speak up or do a mistake we’re going to kick you out.

Doctors are already in a tough place, under attack from nearly every quarter — including, for these past few episodes, Freakonomics Radio. And the fear of making a mistake — or what may be construed as a mistake — is already so high that doctors practice way too much “defensive” medicine; that is, tests and procedures primarily meant to avoid a malpractice suit.

A 2010 study found that U.S. hospitals and doctors spent about $45 billion a year on defensive medicine. But if the present looks occasionally bleak, the good news is there’s plenty of optimism about the future of medicine — as we learned from the variety of clever and motivated people we’ve spoken to for this series.

WOODRUFF: Where science and medicine is going in the future is to more and more precision medicine, so that we can get closer to an autonomous and individualized diagnosis.

That’s Teresa Woodruff, a professor at Northwestern and director of the Women’s Health Research Institute.

WOODRUFF: When someone comes in with a cancer, there is a set of protocols, there is the way we treat, in general, populations, but we can’t tell the specific outcome for that individual. How will they tolerate that drug? Will it clear the circulation faster for one individual versus another — which means it might be more efficacious or less efficacious on an individual basis. Those are some of the precision medicine that eventually we have to get to.

DUBNER: So I promise not to hold you to the prediction I’m about to ask you to make, but in terms of precision medicine like you’re talking about — whether it’s diagnostic, prescriptive, whatever it is — I just want to know what kind of timeframe you see for that being a real practical everyday thing. Is it more like 2 to 20 years, or is it more like 50 to 100 years from now, somewhere in between or somewhere beyond?

WOODRUFF: I think science is becoming even more catalytic, so it’s going faster and faster and faster. Breakthroughs are coming about every day. And I suspect within the next 10 to 15 years we’ll really understand enough to get away from radiation and chemotherapy. And that eventuality is the promise of basic science in medicine. And what that means is that every day as we discover more and more fundamental biology, about cells, or about animals, or about the way systems work, that translates into better and better medicines that ultimately will change the patient who is seen tomorrow versus the way the patient that’s seen today.

JEREMY GREENE: There’s a lot of promise right now that in the post-genomic world, some personalized medicine or precision medicine will allow us to do that much better.

Jeremy Greene, a physician and historian of medicine at Johns Hopkins.

GREENE: Although at present that’s still highly promissory except for a few very well circumscribed cases. Some people will or won’t respond to a certain drug for hypertension. You fish around you try one, you try another and then you find a cocktail that works for them. Other people will develop allergies to specific medicines. And then you’re constrained in ways that you hadn’t originally anticipated.

PRASAD: I think the game is going to be the same game, which is a game where, if we’re really honest, perhaps a lot of the low-hanging fruit in medicine has been plucked, some of the great interventions.

And that again is Vinay Prasad.

PRASAD: Now it’s a matter of sorting out interventions with medium to small benefits. But that’s okay, but with the medium and small benefit you really have to be sure that you can minimize bias. You can minimize the role of your own sort preconceived notions and that’s why we need careful, randomized studies.

But the biggest reason for optimism, Prasad argues, doesn’t have to do with better evidence, or better protocols, or better medicine, per se. It has to do with better thinking. And that, he says, is happening.

PRASAD: I see it everyday in medicine. I see it in movements like in the British Medical Journal’s really commitment to evidence to transparency, to data sharing. I see it in JAMA journal medicine’s commitment to knowing when more is harmful, when too much medicine is harmful, and that took many years for us to realize. I think we are increasingly allowing people with diverse points of view in medicine, contrarians, perhaps even like myself, to write articles in really important journals so they can be read and thought of by other people. So I think we’re at a moment where, you know we’re much more open to different ideas on how to move medicine forward.